The Furlow Palatoplasty for Velopharyngeal Dysfunction: Velopharyngeal Changes, Speech Improvements, and Where They Intersect

Secondary Procedures on the Palate to Correct/Improve Speech: Past, Present and Future

Speech production in general and in patients with cleft palate in particular is multifactorial. In addition to the complex velopharyngeal mechanism, all structures of the oral cavity have some contribution for correct speech production. Therefore, in addition to the velopharynx the surgeons and other cleft/craniofacial team members need to perform a thorough and complete evaluation of all structures to fully appreciate the causative factor(s) responsible for inadequate speech production after palatoplasty and to prescribe the most appropriate, personalized management plan. The purpose of this communication is to stress the importance of areas other than the velopharyngx that could have a negative impact on speech. More specifically, the issues of palatoplasty failures and palatal revisions will be presented. This is an area of significant importance and could represent the first line of defense before considering procedures altering the anatomy of the velopharynx, such as pharyngeal flaps, pharyngoplasties, and others. Issues covering the effects of skeletal and dental problems, such as malocclusion, partial or complete edentulism can also affect speech but are outside the scope of this communication.

Proposed clinical model for predicting speech outcomes in patients undergoing Furlow palatoplasty for velopharyngeal insufficiency after primary palatoplasty

This study aimed to validate the predictors of speech outcomes following Furlow palatoplasty in patients with velopharyngeal insufficiency (VPI) after primary palatoplasty and to propose and validate a model to predict the risk of persistent VPI. The study included patients with VPI after primary palatoplasty who underwent Furlow palatoplasty as a secondary surgery. Eleven variables were included: velar length, pharyngeal cavity depth, velopharyngeal gap, velopharyngeal closure pattern, sex, presence of cleft lip, existence of palatal fistula, surgeon, age at primary palatoplasty, age at secondary surgery, and time interval between primary palatoplasty and secondary surgery. Postoperative speech outcomes were assessed at least 1 year after the secondary surgery and classified as velopharyngeal competence (VPC) or VPI. Variables were analyzed using multivariate logistic regression analysis, and the area under the curve (AUC) was used to validate model accuracy. The study sample comprised 101 patients. Of the patients, 62 had VPC and 39 had VPI after secondary surgery. The results showed a younger age at secondary surgery, a smaller velopharyngeal gap, being female, having a coronal velopharyngeal closure pattern and a velopharyngeal closure ratio of 90% or greater produced a greater probability of VPC. Given the constraints of this study, it appears that the Furlow palatoplasty should be prioritized when the clinical model predicts a substantial likelihood of VPC post-surgery.

Single Oral Z-Plasty: A Clinical Validation of a Technique for Palatal Lengthening in Primary and Secondary Cleft Palate Repair

BACKGROUND

In cleft palate repair, palate length is associated with improved speech outcomes. Although direct closure offers poor palatal lengthening, use of two opposing Z-plasties may reorient palatal musculature and lengthen the velum. The authors previously described a novel overlapping intravelar veloplasty to achieve longitudinal closure of the nasal mucosa with a single oral Z-plasty (1ZP), lengthening the palate in cadaver studies. This study aims to corroborate this finding in clinical cases.

METHODS

A retrospective comparative study of patients with a cleft palate was conducted. Patients underwent cleft palate closure with 1ZP or intravelar veloplasty with straight-line closure. Preoperative and postoperative measurements of the palate along four dimensions were recorded. Analysis was conducted on preoperative and postoperative measurements within and between groups using the Mann-Whitney-Wilcoxon or chi-square test.

RESULTS

Eighty-five patients were included (1ZP, n = 65; straight-line closure, n = 20). 1ZP increased soft palate length (SPL) by 33% ( P < 0.001) and total palate length (TPL) by 10% ( P < 0.001). Primary 1ZP increased SPL by 33% ( P < 0.001) and TPL by 10% ( P < 0.001). Secondary 1ZP increased SPL by 28% ( P < 0.001) and TPL by 8% ( P < 0.001). When comparing between primary and secondary 1ZP, 1ZP was equal with regard to percentage lengthening in SPL ( P > 0.9) and TPL ( P > 0.3). When compared with straight-line closure, 1ZP showed superior percentage lengthening in SPL ( P < 0.001) and TPL ( P = 0.038).

CONCLUSIONS

1ZP results in a statistically significant increase in palate length in both primary and secondary cleft palate repair. This technique provides an effective alternative in patients for whom 2ZP is not feasible.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Comparative Effectiveness of Secondary Furlow and Buccal Myomucosal Flap Lengthening to Treat Velopharyngeal Insufficiency

Background

Secondary Furlow (Furlow) and buccal myomucosal flaps (BMMF) treat velopharyngeal insufficiency by lengthening the palate and retropositioning the levator veli palatini muscles. The criteria for choosing one operation over the other remain unclear.

Methods

A single-center retrospective cohort study was conducted. Thirty-two patients with nonsyndromic, repaired cleft palate were included. All patients underwent a Furlow or BMMF. Outcome measures included (1) resolution of hypernasality 12 months postoperatively, (2) degree of improvement of hypernasality severity; and (3) change in velar length, as measured on magnetic resonance imaging scans obtained preoperatively and 12 months postoperatively. All measures were performed by raters blinded to participants' medical and surgical history.

Results

Hypernasality was corrected to normal in 80% of the Furlow group and in 56% of the BMMF group. Patients receiving BMMF had more severe hypernasality during preoperative speech evaluation. Both groups had a median decrease of two scalar rating points for severity of hypernasality (P = 0.58). On postoperative magnetic resonance imaging, patients who underwent Furlow had a median increased velar length of 6.9 mm. Patients who received BMMF had a median increased velar length of 7.5 mm. There was no statistically significant difference between groups regarding increase in velar length (P = 0.95).

Conclusions

Furlow and BMMF procedures increase velar length with favorable speech outcomes. The same degree of improvement for hypernasality was observed across groups, likely explained by the similar increase in velar length achieved. Anatomic changes in palate length and levator veli palatini retropositioning persist 1 year after surgery.

Buccal Fat Pad in Primary and Secondary Cleft Palate Repair: A Systematic Review of the Literature

OBJECTIVE

To review the evidence supporting the use of buccal fat pad (BFP) in primary and secondary cleft palate repair and its short- and long- term clinical outcomes.

DESIGN

Systematic review conducted by 2 independent reviewers following PRISMA guidelines.

SETTING: NONE PARTICIPANTS

Articles were identified from three databases (Pubmed/Medline, Embase and Web of Science). Search terms included "cleft palate", "palatoplasty", "palate repair", "buccal fat pad".

INTERVENTIONS

Use of BFP in primary and secondary cleft palatoplasty.

MAIN OUTCOME MEASURES

Primary outcomes were immediate postoperative complications, postoperative fistula, and maxillary growth. Secondary outcomes were palatal length, speech, and donor site morbidity.

RESULTS

Ninety-one reports were retrieved after excluding duplicates. Twenty-three studies were included (13 case series and 10 comparative studies). Overall level of evidence was low. Randomized and non-randomized studies had a high risk of bias. In primary palatoplasty, BFP was more frequently used filling lateral relaxing incisions(57.4%), or in the hard-soft palate junction and covering mucosal defects(30.1%). In these patients, post operative fistula incidence was 2.8%. Two studies found wider transverse maxillary dimensions after BFP use. No higher incidence of bleeding, infection, dehiscence, or flap necrosis was reported. In secondary palatoplasty, no recurrent fistulas were reported for patients undergoing BFP for fistula repair.

CONCLUSIONS

BFP appears to be associated with a favorable impact in fistula prevention and management, as well as in transverse maxillary growth. However, there is a high heterogeneity among studies, high risk of bias and overall low quality of evidence. More high-quality research with long-term follow-up is warranted.

Surgery for Velopharyngeal Insufficiency Following Cleft Palate Repair: An Audit of Contemporary Practice and Proposed Schema of Techniques and Variations

OBJECTIVE

Surgical treatment of velopharyngeal insufficiency (VPI) includes a wide array of procedures. The purpose of this study was to develop a classification for VPI procedures and to describe variations in how they are performed.Design/participants/setting/outcomes: We completed an in-depth review of the literature to develop a preliminary schema that encompassed existing VPI procedures. Forty-one cleft surgeons from twelve hospitals across the USA and Canada reviewed the schema and either confirmed that it encompassed all VPI procedures they performed or requested additions. Two surgeons then observed the conduct of the procedures by surgeons at each hospital. Standardized reports were completed with each visit to further explore the literature, refine the schema, and delineate the common and unique aspects of each surgeon's technique.

RESULTS

Procedures were divided into three groups: palate-based surgery; pharynx-based surgery; and augmentation. Palate-based operations included straight line mucosal incision with intravelar veloplasty, double-opposing Z-plasty, and palate lengthening with buccal myomucosal flaps. Many surgeons blended maneuvers from these three techniques, so a more descriptive schema was developed classifying the maneuvers employed on the oral mucosa, nasal mucosa, and muscle. Pharynx-based surgery included pharyngeal flap and sphincter pharyngoplasty, with variations in design for each. Augmentation procedures included palate and posterior wall augmentation.

CONCLUSIONS

A comprehensive schema for VPI procedures was developed incorporating intentional adaptations in technique. There was substantial variation amongst surgeons in how each procedure was performed. The schema may enable more specific evaluations of surgical outcomes and exploration of the mechanisms through which these procedures improve speech.

Objective and subjective evaluation of Velopharyngeal Dysfunction (VPD) following surgical repair of the cleft palate using the furlow palatoplasty - A new tool

Velopharyngeal dysfunction (VPD) diagnosis and speech surgery outcomes are currently based solely on subjective evaluation criteria consisting of perceptual speech assessment and functional imaging. This study describes an objective and comparable method in VPD assessment and investigates the concurrence between the objective and subjective evaluations. The present study included 20 paediatric patients presenting with VPD after primary repair (intravelar veloplasty) of cleft palate. Our protocol was based on computerized analysis of voice parameters by means of an objective tool, spectrography integrated with Multi-Dimensional Voice Program (MDVP). The protocol also included perceptual evaluation by speech therapist and phoniatrician (consensus listening), and parents. This is a single surgeon, single centre experience and all patients underwent a secondary Furlow's palatoplasty. Assessments were performed pre- and postoperatively and upon completion of speech therapy. Results were compared using the two-tailed t student test for paired data. Statistical significance was set for p-values <0.05. Data analysis confirmed an improvement in velopharyngeal closure after surgery and speech therapy consistently with the results of perceptual evaluations. The results of the study confirmed the availability and reliability of an objective method for VPD evaluation based on the analysis of voice parameters with investigations that are simple and easily available in a hospital setting.

Surgical interventions in velopharyngeal dysfunction: comparative perceptual speech and nasometric outcomes for three techniques

Background

The aim of this study was to evaluate speech outcomes following surgical intervention for velopharyngeal dysfunction (VPD). Perceptual speech outcome data were subsequently analyzed in conjunction with patient factors such as congenital abnormalities, presence of cleft lip and/or palate, and age of repair. We hope to aid in the eventual creation of treatment algorithms for VPD, allowing practitioners to tailor surgical technique selection to patient factors.

Methods

A retrospective analysis was performed for all patients who underwent surgical correction of VPD at London Health Sciences Centre between the years 2005 and 2018. Two hundred and two consecutive VPD patients (median age 10.6 years) were followed for an average of 20.2 months after having undergone a superiorly based pharyngeal flap (121), Furlow palatoplasty (72), or sphincteroplasty (9). Speech outcomes were measured via the American Cleft Palate-Craniofacial Association (ACPA) perceptual speech assessment, and MacKay-Kummer Simplified Nasometric Assessment Procedures Revised (SNAP-R) was used to measure nasalence. Comparisons of mean preoperative and postoperative outcomes were made, as well as analyses regarding surgical procedure, syndrome, cleft status, and age.

Results

Mean perceptual scores improved significantly postoperatively (p < .0001), and successful perceptual resonance was identified in 86.1% patients (n = 174). Postoperative perceptual speech scores for three ACPA domains were superior with pharyngeal flap compared to both Furlow palatoplasty and sphincteroplasty ([hypernasality: p < .001, p < .02], [audible nasal emissions: p < .002, p < .05], [velopharyngeal function: p < .001, p < .05]). Success rate was higher in pharyngeal flap (94.2%) than in Furlow palatoplasty (75.0%, p < .001) or sphincter pharyngoplasty (66.7%, p < .001). No significant difference was identified in success rate based on syndrome or cleft status.

Conclusion

Operative management of VPD is highly effective in improving perceptual speech outcomes. Given proper patient selection, all three procedures are viable treatment options for VPD. For those patients identified as appropriate to undergo a pharyngeal flap, robust improvements in speech outcomes were observed.

Graphical abstract

Square-root Palatoplasty: Comparing a Novel Modified-Furlow Double-opposing Z-palatoplasty Technique to Traditional Straight-line Repair

The purpose of this study was to introduce a modification of the Furlow double-opposing Z-plasty (DOZ)-the square-root palatoplasty (SRP)-and critically evaluate outcomes compared to children who underwent straight-line repair (SLR).

Methods

A retrospective review was performed of all nonsyndromic children undergoing primary cleft palate closure either by SRP or SLR at our institution between 2009 and 2017. Outcomes of interest included rates/location of oronasal fistula, secondary surgery, speech delay/deficits, resonance, nasal air emission (NAE), articulation errors, and velopharyngeal function. Logistic regression was used to assess for the effect of surgery type on outcomes while controlling for Veau cleft type, age, and gender.

Results

Seventy-eight patients were included; 46 (59%) underwent SRP, and 32 (41%) underwent SLR. The mean follow-up was 4.07 years. When compared to SLR, children who underwent SRP were less likely to have oronasal fistula [odds ratio (OR) 4.8, P = 0.0159], speech delay/deficits (OR 7.7, P < 0.001), NAE (OR 9.7, P < 0.001), articulation errors (OR 10.2, P < 0.001), or need for secondary speech surgery (OR 13.2, P < 0.0002). Patients who underwent SRP were also more likely to have normal resonance (78.26% versus 43.75%, respectively; P = 0.0043) and good VP function (84.78% versus 56.25%, respectively; P = 0.0094).

Conclusions

This study describes and evaluates outcomes following a modified-Furlow DOZ technique-the SRP. After adjusting for Veau classification, age, and gender in nonsyndromic children, SRP is associated with significantly less speech delay/deficits, NAE, articulation errors, and need for secondary speech surgery when compared to children who underwent SLR.

Double-opposing Z-Plasty Extended with a Pedicled Buccal Fat Pad Flap for Correcting Velopharyngeal Insufficiency after Primary Palatoplasty

INTRODUCTION

Furlow double-opposing Z-plasty (DOZ) lengthens the soft palate; however, this lengthening is achieved at the expense of increased mucosal flap tension. Thus, its use is limited in patients with severe tension applied on mucosal flap after DOZ. In this study, DOZ was combined with a buccal fat pad (BFP) flap to maximize palatal lengthening and muscle repositioning.

METHODS

This study included patients who underwent surgical correction for velopharyngeal insufficiency between December 2016 and February 2019. Patients with more than moderate degree hypernasality following primary palatoplasty were included in the study. Patients younger than 4 years of age, those with a submucous cleft palate, or syndromic patients were excluded. Speech outcomes were investigated for those who underwent DOZ only (DOZ group, n = 17) and those in whom a BFP was used (BFP group, n = 15) pre- and postoperatively. The velopharyngeal gaps between the uvula and pharyngeal wall were measured before and immediately after surgery to estimate the palatal length.

RESULTS

Most patients who received a BFP showed improvement in hypernasality. However, the hypernasality of the DOZ group was more severe than that of the BFP group (p = 0.023). The extent of palatal lengthening was 4.4 ± 1.7 mm and 7.5 ± 2.1 mm in the DOZ and BFP groups, respectively (p = 0.001).

CONCLUSIONS

BFPs reduced the tension of the DOZ mucosal flap and maximized palatal lengthening and muscle repositioning. They promoted velopharyngeal closure in patients with moderate and moderate-to-severe velopharyngeal insufficiency. Hence, our method improves the surgical outcomes of patients with velopharyngeal insufficiency after primary palatoplasty.

Furlow Palatoplasty for Velopharyngeal Dysfunction Management: Auditing and Predicting Outcomes

OBJECTIVE

The Furlow palatoplasty is a proven procedure in the management of secondary velopharyngeal dysfunction in patients with cleft palate. But the selection of cases, the degree of clinical success, and the preoperative predictors of the same are less established. This study is an effort to retrospectively look at outcomes, in a large series of velopharyngeal dysfunction cases treated with the Furlow palatoplasty alone.

DESIGN

Retrospective analysis of preoperative and postoperative speech and videofluoroscopic data.

SETTING

Tertiary care center.

PATIENTS/PARTICIPANTS

Ninety-two patients who were diagnosed with velopharyngeal dysfunction post primary cleft palate repair.

INTERVENTIONS

Furlow palatoplasty for velopharyngeal dysfunction post primary cleft palate repair.

MAIN OUTCOME MEASURES

Variables analyzed were perceptual speech parameters and, closure ratios obtained from lateral video-fluoroscopic images.

RESULTS

Overall, 81.5% had postoperative improvements in their lateral video-fluoroscopic parameters, 63% improved their nasality scores, and 65.2% had improved speech intelligibility. A simple linear regression was done to predict the postoperative closure ratio. Preoperative closure ratio, hypernasality (moderate and severe), and audible nasal air emission are predictors for postoperative closure ratio.

CONCLUSIONS

The Furlow palatoplasty alone led to complete resolution, or significant improvement of velopharyngeal dysfunction in a majority of patients, despite the cohort having a wide range of severity in terms of degree of dysfunction. The predictive formula will be validated in a further study.

Evaluation of fistula rates in three cleft palate techniques without relaxing incisions

The aim of the present study was to investigate the incidence of postoperative fistula formation from a hybrid cleft palate repair compared to that from two well-established techniques. We performed a modified technique, Sommerlad-Furlow (SF), which combined the repositioning of the levator veli palatini muscles as described by Sommerlad with the double opposing Z-plasty of Furlow to lengthen the soft palate. A retrospective cohort study was conducted to evaluate patients who underwent cleft palate repair utilizing SF, Sommerlad, or Furlow techniques with the incidence of palatal fistula as the target endpoint. A total of 1,164 patients were included in the present study and underwent the following techniques: 603 cases with SF, 244 cases with Furlow, and 317 cases with Sommerlad. In addition to not requiring relaxing incisions, SF advantages included a consistently lower fistula rate compared to that of the Sommerlad technique, as well as the lowest fistula rate in patients with both hard and soft palate clefts without a cleft lip (OR:2.62 95% CI: 1.35, 5.09). However, the differences among the three techniques did not reach statistical significance in terms of a bilateral or unilateral cleft lip/palate, or in patients with a soft palate only or a submucosal cleft palate(OR: 2.22,95% CI:0.77, 6.37). Based on the results of our study, the Somerlad-Furlow technique should be preferred whenever possible.

Complications and the Need for Long-Term Follow-Up after Secondary Speech Surgery: A National and Longitudinal Claims Analysis

BACKGROUND

Although most patients attain normal speech after cleft palate repair, up to 20 percent require secondary speech surgery. Despite the frequency of these procedures, complications and rates of subsequent revisions of secondary speech surgery after all procedure types have never been reviewed using national, longitudinal data.

METHODS

The authors examined insurance claims from Clinformatics Data Mart between 2001 and 2017. Cases were categorized as palatalprocedures (i.e., palatoplasty, revision palatoplasty, secondary lengthening, palatal island flap) or pharyngeal procedures (i.e., pharyngeal flap, dynamic sphincter pharyngoplasty) (n = 846). Continuous enrollment from 180 days before to 30 days after surgery was required. Patients were excluded if they underwent palatoplasty, or any surgery at less than 3 years of age, without a speech diagnosis. Outcomes included 30-day complications and rates of subsequent revision secondary speech surgery. Multivariable logistic regression was used to evaluate the relationship between procedure type and complications.

RESULTS

In this cohort, 52.5 percent underwent pharyngeal procedures, and 47.5 percent underwent palatal procedures. Complications occurred in 10.9 percent of patients and included respiratory complications (4.0 percent), bleeding (1.2 percent), dehiscence (3.6 percent), and critical care episodes (3.0 percent). There was no difference in complications between procedure types (OR, 0.87; 95 percent CI, 0.56 to 1.37; p = 0.56). The subsequent revision rate was 12.7 percent, but was 21.7 percent in patients with 3 years of postoperative enrollment.

CONCLUSIONS

Although complication rates were comparable to those in recent literature, rates of subsequent revisions of secondary speech procedures were high in patients with longer postoperative enrollment. Thus, these patients merit prolonged follow-up, as velopharyngeal dysfunction may recur over time.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Comparison of two-flap palatoplasty plus intravelar veloplasty technique with and without double-layer Z-plasty on the soft palate length in children with cleft palate

PURPOSE

Velopharyngeal failure occurs as a result of a nasopharyngeal gap following inadequate velopharyngeal closure for structural or functional cause. We aimed to compare the soft palate length in two-flap palatoplasty with intravelar veloplasty (IVV) and two-flap palatoplasty with IVV plus double-layer Z-plasty combination in patients with cleft palate.

METHODS

This clinical trial was conducted on infants aged 9 to 12 months with cleft palate in two groups. The method of two-flap palatoplasty with IVV technique and two-flap palatoplasty with IVV plus double-layer Z-plasty was compared in terms of soft palate length which was measured during operation and short-term complications.

RESULTS

This study was conducted on 62 infants including 30 patients in two-flap palatoplasty with IVV group and 32 patients in two-flap palatoplasty with IVV plus double-layer Z-plasty group. The soft palate length in two-flap palatoplasty and IVV with and without Z-plasty groups before surgery was 17.56 ± 2.05 and 17.68 ± 1.88 mm, respectively (P = 0.561). After surgery, the soft palate length was significantly higher in two-flap palatoplasty with IVV plus Z-plasty group (22.43 ± 2.73 mm vs. 20.56 ± 2.42 mm) (P = 0.032).

CONCLUSION

The two-flap palatoplasty with IVV plus Z-plasty technique is a suitable method for increasing the palatal length in infants with cleft palate. On the other hand, the addition of Z-plasty method could increase the length of the palate. Moreover, the complications are very low and further trials for development of this method on patients with cleft palate are recommended.

TRIAL REGISTRATION NUMBER (TRN)

IRCT2017032423559N11.

[Use of fixed individual micro-implant supported orthodontic appliance in children with bilateral cleft lip and palate]

Congenital malformations of the maxillofacial region are significant, not completely decisive, medical and social problems. Recent literature data indicate a trend towards improvement.

PURPOSE OF THE STUDY

Improving the effectiveness of treatment of children with bilateral orthodontic and surgical training.

MATERIAL AND METHODS

Under the supervision were 80 children with cleft lip and palate, with an age of up to 3 years. Of these 56 patients, 28 patients are the 2nd group prepared for surgery according to the developed technique.

RESULTS

Preoperative orthodontic preparation of 28 children with bilateral cleft and an indicator that 22 (78.6%) patients should not have fully achieved results between the interhuman and fragmentary alveolar process of the upper jaw. In the second group of patients, 27 (96.4%) patients showed a normal ratio of the intermaxillary bone and lateral fragments.

CONCLUSION

The use of the developed orthodontic design with active elements and mini implants in 96.4% of cases requires the presence of pre-spiral orthodontic preparation, normalization of the position of the intercellular bone and shape, followed by primary chelorinoplastics and in relation to additional uranoplastics, as well as the periodic stages of rehabilitation of patients with bilateral cleft lip and achieved thereby a stable aesthetic and functional result.

A Comparative Study Evaluating Speech Outcomes in Classic versus Occult Submucous Cleft Palate Using a Primary Furlow Palatoplasty Technique

BACKGROUND

No consensus exists on the selection of procedures for the treatment of submucous cleft palate, with scarce reports on long-term outcomes from single-surgeon experience. This study assessed the outcomes of using extended indication criteria of Furlow palatoplasty as the first-line procedure for the management of submucous cleft palate-associated velopharyngeal insufficiency.

METHODS

Consecutive nonsyndromic patients with submucous cleft palate (n = 216) treated by a single surgeon between 1998 and 2018 were reviewed. Furlow palatoplasty was performed in all patients diagnosed with submucous cleft palate-associated velopharyngeal insufficiency, regardless of the age cutoff, number of Calnan triad features, or velopharyngeal gap size and pattern. Postoperative velopharyngeal function outcome (adequate, marginal, or inadequate) and the need for secondary surgery were investigated. Age at surgery, sex, submucous cleft palate type (classic and occult), and presence of complication were evaluated for potential associations with this outcome.

RESULTS

Forty-seven patients aged 8.3 ± 4.6 years with occult submucous cleft palate were significantly (p < 0.001) older than those with the classic type (n = 169; 5.6 ± 3.1 years). Most (p < 0.001) of the included patients [n = 181 (83.8 percent)] achieved adequate postoperative velopharyngeal function outcome. Three patients (1.4 percent) presented surgery-related complications, including bleeding and partial wound disruption. Secondary speech surgery was recommended in 24 patients (11.1 percent). In the bivariate and multivariate analyses, none of the tested variables was found to be associated (all p > 0.05) with the postoperative velopharyngeal function outcome.

CONCLUSION

The extended indication criteria of Furlow palatoplasty provided adequate velopharyngeal insufficiency management with a low complication rate and satisfactory speech outcome.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Velopharyngeal Muscle Morphology in Children With Unrepaired Submucous Cleft Palate: An Imaging Study

OBJECTIVE

To identify quantitative and qualitative differences in the velopharyngeal musculature and surrounding structures between children with submucous cleft palate (SMCP) and velopharyngeal insufficiency (VPI) and noncleft controls with normal anatomy and normal speech.

METHODS

Magnetic resonance imaging was used to evaluate the velopharyngeal mechanism in 20 children between 4 and 9 years of age; 5 with unrepaired SMCP and VPI. Quantitative and qualitative measures of the velum and levator veli palatini in participants with symptomatic SMCP were compared to noncleft controls with normal velopharyngeal anatomy and normal speech.

RESULTS

Analysis of covariance revealed that children with symptomatic SMCP demonstrated increased velar genu angle (15.6°, P = .004), decreased α angle (13.2°, P = .37), and longer (5.1 mm, P = .32) and thinner (4 mm, P = .005) levator veli palatini muscles compared to noncleft controls. Qualitative comparisons revealed discontinuity of the levator muscle through the velar midline and absence of a musculus uvulae in children with symptomatic SMCP compared to noncleft controls.

CONCLUSIONS

The levator veli palatini muscle is longer, thinner, and discontinuous through the velar midline, and the musculus uvulae is absent in children with SMCP and VPI compared to noncleft controls. The overall velar configuration in children with SMCP and VPI is disadvantageous for achieving adequate velopharyngeal closure necessary for nonnasal speech compared to noncleft controls. These findings add to the body of literature documenting levator muscle, musculus uvulae, and velar and craniometric parameters in children with SMCP.

Palatal lengthening by double opposing buccal flaps for surgical correction of velopharyngeal insufficiency in cleft patients

AIM

To assess the efficacy of double opposing buccal flap in lengthening the soft palate for velopharyngeal insufficiency correction, and its potential complications in different age groups.

CASE SERIES

From March 2016 to June 2019, 50 patients (24 children, 12 adolescents and 14 adults) underwent palatal lengthening using double opposing buccinator myomucosal flaps. Postoperative complications were assessed by two surgeons and the speech outcomes were evaluated by two speech-language pathologists after assessing changes in the hypernasality and intelligibility using a scoring approach. Following the procedure, mild-to-moderate surgical complications were seen, mostly among the adults. There was a significant improvement in hypernasality and intelligibility in all the groups. None of the patients showed hyponasal speech postoperatively.

CONCLUSION

To conclude, the double opposing buccal flap technique is an effective and safe surgical treatment option for the management of velopharyngeal insufficiency in all age groups of patients.

Surgical, Speech, and Audiologic Outcomes in Patients With Orofacial Cleft and Van der Woude Syndrome

OBJECTIVE

The purpose of this study was to investigate the surgical, speech, and audiologic outcomes in patients with Van der Woude syndrome (VWS) and compare them to patients with nonsyndromic cleft palate with or without cleft lip (NS-CP ± L) treated at the same institution.

DESIGN

Retrospective chart review.

SETTING

A single children's hospital at a major academic institution.

PATIENTS

The records of 18 patients with VWS who had been treated at a single institution from 1989 to 2017 have been retrospectively examined. Thirty-eight patients with NS-CP ± L who were also treated at the same institution during that same time frame were selected to closely match sex and date of birth.

MAIN OUTCOME MEASURES

Demographic, clinical, surgical, and speech pathology data were gathered from medical charts.

RESULT

By age 4, 88% of subjects with VWS and 76% of subjects with NS-CP ± L (P = 0.732) had been, or were actively involved in, speech therapy. By age 10, 100% of remaining subjects with VWS and 58% of remaining subjects with NS-CP ± L remained involved in speech therapy (P = 0.027).About 33% of patients with VWS and 16% of patients with NS-CP ± L had a secondary procedure for velopharyngeal dysfunction (VPD) (P = 0.171).

CONCLUSION

The VWS group had more than twice the rate of secondary procedures for VPD repair, and a higher rate of continuing involvement for speech therapy at age 10. No differences were found in the rate of participation in speech therapy at or by age 4.

Speech and language characteristics in individuals with nonsyndromic submucous cleft palate-A systematic review

BACKGROUND

Up to 80% of individuals with unrepaired submucous cleft palate (SMCP) experience speech difficulties secondary to velopharyngeal insufficiency. Language delays are reported in the broader cleft lip and/or palate population, suggesting that individuals with SMCP may also be at risk. However, contemporary understanding of this population remains limited as there has been no systematic examination of the literature. This review aims to systematically review and document the speech and language characteristics of individuals with nonsyndromic SMCP and, in addition, to identify factors reported to impact speech and language outcomes.

METHOD

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Five databases were comprehensively searched using keywords and indexed headings. Included studies had to report speech or language outcomes of individuals with nonsyndromic SMCP. Risk of bias and methodological design quality were examined using tools from the Scottish Intercollegiate Guidelines Network. Relevant data were extracted for analysis.

RESULTS

Eighteen studies met inclusion criteria, yielding 598 participants. Study results showed that individuals with unrepaired nonsyndromic SMCP may have speech difficulties secondary to velopharyngeal insufficiency including increased nasal resonance and palatalized or glottal articulation. Lower age at primary surgical repair led to better postsurgical speech outcomes. There is a paucity of literature outlining motor or phonological aspects of speech and receptive or expressive language abilities of this population.

CONCLUSION

Individuals with nonsyndromic SMCP present with speech difficulties similar to those experienced by individuals with overt cleft palate. Health care professionals should be aware of possible presenting symptoms and consider early SMCP diagnoses where appropriate. Further research is needed to specify the broader communication profile in this population.

Palatal Measurements Pre- and Post-Furlow Cleft Palate Repair: Analysis of Palatal Lengthening and Comparison Within Cleft Types

Objective:

The purpose of this study was to characterize intraoperative palatal lengthening with the modified Furlow cleft palatal repair and to determine whether lengthening correlated with preoperative cleft width, cleft type, or operating surgeon.

Design:

Retrospective study.

Setting:

Academic tertiary care pediatric hospital.

Patients:

One hundred eighty pediatric patients undergoing primary or secondary palatoplasty using the Furlow technique.

Interventions:

Cleft and palatal lengths and widths were measured pre- and post-Furlow cleft palatal repair.

Main Outcome Measures:

Immediate postoperative percentage change in surface palate length, straight palate length, and soft palate length.

Results:

The average cleft widest width and width at the hard–soft palate junction were 10.2 and 9.5 mm, respectively, and varied with Veau cleft type. Following Furlow palatoplasty, lengths of the curved, straight, and soft palate increased by 7.5%, 15.8%, and 30.6%, respectively. Degree of palatal lengthening varied among surgeons and Veau cleft type but was not related to cleft width. Seven (4.0%) patients developed postoperative oronasal fistulas. Patients with a Veau IV cleft and larger cleft widths were at an increased risk for fistula formation.

Conclusions:

This study demonstrates that overall palatal lengthening occurs with the modified Furlow technique. Long-term follow-up studies are needed to determine the clinical relevance of these findings.

Effects of Surgical Intervention and Continuous Positive Airway Pressure Therapy on Velopharyngeal Structure and Function: A Case Report

Changes to the velum and velopharyngeal muscles following Furlow double-opposing Z-plasty in a 7-year-old female with submucous cleft palate and velopharyngeal dysfunction (VPD) were evaluated. Perceptual, instrumental (ie, nasometry and aerodynamic pressure flow), and research magnetic resonance imaging analyses were used during pre- and postsurgical time points at a university research clinic. Continuous positive airway pressure (CPAP) therapy was trialed following a failed surgery for residual VPD in the patient. Increases in velar length and thickness and decreases in levator veli palatini muscle angle of origin and contraction were observed following the Furlow double-opposing Z-plasty surgery. Variable improvements in residual hypernasality following the home-based CPAP therapy protocol were observed.

Single Z-Plasty Versus Double-Opposing Z-Plasty: A Cadaveric Study of Palatal Lengthening

OBJECTIVE

The double-opposing Z-plasty is an effective method of repairing the cleft palate due to its reorientation of the palatal musculature and lengthening of the soft palate. A technique for lengthening the palate with a single oral Z-plasty has also been described. The authors hypothesize that these 2 techniques have equivalent effects on palate length.

METHODS

A cadaver study was performed. Ten fresh adult cadaver heads were used.All palates were divided in the midline. In 5 specimens, a modified double-opposing Z-plasty technique was used; 5 other specimens underwent an oral Z-plasty with a straight-line repair of the nasal mucosa. In both groups, the levator veli palatini muscles were separately dissected and reapproximated with an intravelar veloplasty. The velar length, defined in this study as the distance from the posterior nasal spine to the tip of uvula, was measured before and after the surgical procedure.

RESULTS

The double-opposing Z-plasty produced a mean increase of 1.0 ± 0.6 cm in velar length (P = 0.023). The single Z-plasty repair resulted in a mean gain of 1.1 ± 0.3 cm (P = 0.001). There was no difference in change in palate length between the 2 procedures (P = 0.941), and no difference in the percentage of soft palate lengthening (24% vs 29%, respectively; P = 0.565).

CONCLUSIONS

A single oral Z -plasty provides palatal lengthening equivalent to that of a double-opposing Z-plasty procedure.

Contributions of the Musculus Uvulae to Velopharyngeal Closure Quantified With a 3-Dimensional Multimuscle Computational Model

The convexity of the dorsal surface of the velum is critical for normal velopharyngeal (VP) function and is largely attributed to the levator veli palatini (LVP) and musculus uvulae (MU). Studies have correlated a concave or flat nasal velar surface to symptoms of VP dysfunction including hypernasality and nasal air emission. In the context of surgical repair of cleft palates, the MU has been given relatively little attention in the literature compared with the larger LVP. A greater understanding of the mechanics of the MU will provide insight into understanding the influence of a dysmorphic MU, as seen in cleft palate, as it relates to VP function. The purpose of this study was to quantify the contributions of the MU to VP closure in a computational model. We created a novel 3-dimensional (3D) finite element model of the VP mechanism from magnetic resonance imaging data collected from an individual with healthy noncleft VP anatomy. The model components included the velum, posterior pharyngeal wall (PPW), LVP, and MU. Simulations were based on the muscle and soft tissue mechanical properties from the literature. We found that, similar to previous hypotheses, the MU acts as (i) a space-occupying structure and (ii) a velar extensor. As a space-occupying structure, the MU helps to nearly triple the midline VP contact length. As a velar extensor, the MU acting alone without the LVP decreases the VP distance 62%. Furthermore, activation of the MU decreases the LVP activation required for closure almost 3-fold, from 20% (without MU) to 8% (with MU). Our study suggests that any possible salvaging and anatomical reconstruction of viable MU tissue in a cleft patient may improve VP closure due to its mechanical function. In the absence or dysfunction of MU tissue, implantation of autologous or engineered tissues at the velar midline, as a possible substitute for the MU, may produce a geometric convexity more favorable to VP closure. In the future, more complex models will provide further insight into optimal surgical reconstruction of the VP musculature in normal and cleft palate populations.

Cleft Palate Repair, Gingivoperiosteoplasty, and Alveolar Bone Grafting

Repair of the cleft palate intends to establish the division between the oral and nasal cavity, thereby improving feeding, speech, and eustachian tube dysfunction all while minimizing the negative impact on maxillary growth. Before palate repair candidacy, timing and surgical method of repair is dependent on comorbid conditions, particularly cardiac disease, mandibular length, and palate width. Additionally, management of the alveolar cleft and the indications for gingivoperiosteoplasty versus secondary alveolar bone grafting is a controversial topic that weighs the risks and benefits of potentially sparing the patient an additional surgery against iatrogenic restriction of facial growth and malocclusion.

A Treatment Protocol for Velopharyngeal Insufficiency and the Outcome

BACKGROUND

A simple algorithm is applied to treat velopharyngeal insufficiency. The purpose of this study was to assess its success rate and complications.

METHODS

The diagnosis includes speech perceptual assessment and nasopharyngoscopy, focusing on velopharyngeal closure ratio. The treatment is composed of a double-opposing Z-plasty for marginal velopharyngeal insufficiency or a pharyngeal flap for moderate to severe velopharyngeal insufficiency. A retrospective chart review was conducted for 84 consecutive nonsyndromic postpalatoplasty patients undergoing velopharyngeal insufficiency surgery from August of 2007 to December of 2014. The demographic, perioperative, and follow-up data were collected. Statistical analyses were performed.

RESULTS

Mean age at velopharyngeal insufficiency surgery was 7.0 years. The overall improvement rate for patients was 86.9 percent. Nine patients in the double-opposing Z-plasty group and two patients in the pharyngeal flap group were refractory to velopharyngeal insufficiency surgery. The improvement rates for each surgical group were 80.4 percent for the double-opposing Z-plasty group and 94.7 percent for the pharyngeal flap group. There were no significant differences in postoperative velopharyngeal function between the coronal and noncoronal groups. Airway-associated complications were observed in nine patients (10.7 percent). The complications in the double-opposing Z-plasty group were observed in two patients (4.3 percent), and none of the patients presented obstructive sleep apnea. Seven patients (18.4 percent) in the pharyngeal flap group showed postoperative snoring, and one (2.6 percent) of them presented with obstructive sleep apnea.

CONCLUSION

The authors' algorithm is a simple patient- and surgeon-friendly strategy to obtain satisfactory improvement of velopharyngeal function for velopharyngeal insufficiency patients, with a low risk of airway complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Investigation of the speech results of posterior pharyngeal wall augmentation with fat grafting for treatment of velopharyngeal insufficiency

PURPOSE

The purpose of this study was to evaluate the speech results of posterior pharyngeal wall augmentation (PPWA) with fat grafting both in the early and late postoperative period, and to clarify the impact of the procedure concomitant with speech therapy.

MATERIALS AND METHODS

This is a prospective case-control study. The study involved 87 cleft palate ± cleft lip patients with velopharyngeal insufficiency (VPI) who has been treated with PPWA. Patients were separated into two groups according to age; the first group consisted of 49 pediatric participants between 6 and 12 years of age and the second group consisted of 38 adolescent participants between 13 and 18 years of age. Preoperative velopharyngeal function and articulation were compared postoperatively at the following time points: the 3rd month, 12th month, 18th month and 24th month. The velopharyngeal function was evaluated with regards to the velopharyngeal closure type and velopharyngeal closure amount, by using the pediatric flexible nasoendoscopy and the nasometer methods. In the nasometer evaluation, nasalance sores were measured by using nonsense syllables and meaningful sentences. The Ankara Articulation Test (AAT) (Ege et al., 2004) was used to detect compensatory articulation products secondary to VPI. Consonant production error types and frequencies were determined according the guidelines stated in the study of Hardin-Jones et al. (2009). These were Pharyngeal Fricatives - Posterior Nasal Fricatives/Stop Production, Glottal Stop Production, Middorsum Palatal Stop Production, Nasal Frictional Production, Posterior Nasal Frictional Production/Phoneme Specific Nasal Emission, use of Nasal Consonants for Oral Consonants, and Replacement of Trills. All the participants received concurrent speech therapy four times, twice in the post-operative period between 1 and 3 months and twice between 3 and 6 months.

RESULTS

PPWA improved the speech performance from the 18th month to 24th month of the postoperative period. AAT assessment of the first group after 24 months comparing the post-PPWA with the preoperative data showed a highly significant decrease with regard to compensatory production errors and hypernasality; however, in the second group, the same comparison revealed a highly significant decrease in regard to the degree of hypernasality and a significant difference in terms of glottal articulation and pharyngealization of fricatives. A circular closure pattern was observed in 17 individuals with cleft palate at a rate of 70.6%.

CONCLUSION

PPWA with concurrent speech therapy is an acceptable surgical method to correct VPI and to improve speech performance.

A computational model of velopharyngeal closure for simulating cleft palate repair

The levator veli palatini (LVP) muscle has long been recognized as the muscle that contributes most to velopharyngeal (VP) closure and is therefore of principal importance for restoring normal speech in patients with a cleft palate. Different surgical reconstructive procedures can utilize varying degrees of LVP overlap, and this study developed a new finite-element model of VP closure designed to understand the biomechanical effects of LVP overlap. A three-dimensional finite-element model was created from adult anatomical dimensions and parameters taken from the literature. Velopharyngeal function was simulated and compared with experimental measurements of VP closure force from a previous study. Varying degrees of overlap and separation of the LVP were simulated, and the corresponding closure force was calculated. The computational model compares favorably with the experimental measurements of closure force from the literature. Furthermore, the model predicts that there is an optimal level of overlap that maximizes the potential for the LVP to generate closure force. The model predicts that achieving optimal overlap can increase closure force up to roughly 100% when compared with too little or too much overlap. The results of using this new model of VP closure suggest that optimizing LVP overlap may produce improved surgical outcomes due to the intrinsic properties of muscle. Future work will compare these model predictions with clinical observations and provide further insights into optimal cleft palate repair and other craniofacial surgeries.

Progressive Tightening of the Levator Veli Palatini Muscle Improves Velopharyngeal Dysfunction in Early Outcomes of Primary Palatoplasty

BACKGROUND

Management of the levator veli palatini with intravelar veloplasty has been shown to improve speech resonance. The senior author has introduced a more aggressive procedure where the levator is separately dissected, overlapped, and tightened. This study compares resonance results from four levator management protocols: non-intravelar veloplasty, Kriens intravelar veloplasty, radical intravelar veloplasty, and overlapping intravelar veloplasty.

METHODS

Retrospective chart review was conducted on 252 patients who underwent primary palatoplasty with speech follow-up at 3 years of age. Velopharyngeal function was evaluated with perceptual speech examinations, and subjects were scored on a four-point scale (0 = normal resonance; 1 = occasional hypernasality/nasal emission/turbulence/grimacing, no further assessment warranted; 2 = mild hypernasality/intermittent nasal turbulence/grimacing, velopharyngeal imaging suggested; and 3 = severe hypernasality, surgical intervention recommended). Fisher's exact test was used to compare outcomes.

RESULTS

A single surgeon performed all the non-intravelar veloplasty (n = 92), Kriens intravelar veloplasty (n = 103), and radical intravelar veloplasty (n = 31), whereas the senior author performed the overlapping intravelar veloplasty (n = 26). Cleft severity proportions were equivalent across the four methods (p = 0.28). Patients who underwent overlapping intravelar veloplasty demonstrated significantly better velopharyngeal function, and none required further imaging or secondary surgery compared with the other three procedures (p < 0.001).

CONCLUSIONS

Speech resonance outcomes at 3 years of age are improved and need for secondary velopharyngeal dysfunction management is reduced with more aggressive levator dissection and reconstruction during primary one-stage palatoplasty. Results were best when the muscle was overlapped.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

A Computational Model Quantifies the Effect of Anatomical Variability on Velopharyngeal Function

PURPOSE

This study predicted the effects of velopharyngeal (VP) anatomical parameters on VP function to provide a greater understanding of speech mechanics and aid in the treatment of speech disorders.

METHOD

We created a computational model of the VP mechanism using dimensions obtained from magnetic resonance imaging measurements of 10 healthy adults. The model components included the levator veli palatini (LVP), the velum, and the posterior pharyngeal wall, and the simulations were based on material parameters from the literature. The outcome metrics were the VP closure force and LVP muscle activation required to achieve VP closure.

RESULTS

Our average model compared favorably with experimental data from the literature. Simulations of 1,000 random anatomies reflected the large variability in closure forces observed experimentally. VP distance had the greatest effect on both outcome metrics when considering the observed anatomic variability. Other anatomical parameters were ranked by their predicted influences on the outcome metrics.

CONCLUSIONS

Our results support the implication that interventions for VP dysfunction that decrease anterior to posterior VP portal distance, increase velar length, and/or increase LVP cross-sectional area may be very effective. Future modeling studies will help to further our understanding of speech mechanics and optimize treatment of speech disorders.